Assessment Flashcards
S3
Aka ventricular gallop
Not normally heard in people with normal heart sounds.
Can be present in healthy children and young adults
When heard in older adults, is often associated with moderate to severe heart failure
Is a soft, low pitched heart sound, when present considered to be “lub-DUB-da”
Often associated with abnormal filling pressures in the atria secondary to heart failure
page 341
Romberg test
Measures your sense of balance
Ptosis
Droopy eyelid
Can be just a little or can droop so much that it covers the pupil
Stridor
Brassy crowing sound often heard without a stethoscope
Caused by narrowing, swelling or obstruction of the upper airway and may indicate the pt has an airway obstruction in the neck or upper part of the chest
Tricuspid valve
Right atrioventricular valve.
Separates the atrium and ventricle on the right side of the heart.
Hearing Acuity
How well/clearly a pt can hear
Tinnitus
Ringing in the ears
Orthostatic vital signs
aka Tilt test
Measures fluid loss/dehydration
Measures BP and pulse rate for changes in supine, sitting and standing position
Considered positive when the pt’s systolic blood pressure decreases up to 20 mmHg, diastolic pressure increases more than 10 mmHg (a narrowing pulse pressure) and pulse rate increases by 20 beats
Take vitals at 1 min intervals between moving a pt to a new position.
Make sure not to take vitals right after moving the pt. You need to wait 2-3 minutes for the pt to be in the new position at least.
page 571
Acuity
Sudden onset Critical Acuit MI Acuit illness Acuit episode
Confabulation
The creation of false memories
Person have no recognition that the information being relayed is fabricated
Going from pounds to kilograms
Number deviled by 2 minus 10%
150 divided by 2 minus 10%
180 deviled by 2 minus 10%
Rhonchi
aka Congested breath sounds
Lower pitch and a rattling quality
May indicate the presence of mucus in the lungs
PERRLA
Pupils
Equal
Round
Reactive to
Light and
Accommodations
S4
Aka atrial gallop
Not normally heard. If heard, almost always abnormal.
Medium pitched heart sound that occurs immediately before the normal S1 sound (like a flam). “bla-lub-DUB”
If present represents either decreased stretching (compliance) of the left ventricle or increased pressure in the atria.
Babinski reflex
Positive (abnormal) younger than 2 - when pt toes curl down
Negative (normal) under 2 - pt pulls away
Positive (abnormal) 2 and older when a pt’s toe(s) flex up from stimulation on the bottom of the foot
Negitive (normal) circumstances the toe(s) flex down if older than 2
Murmur
An abnormal whooshing sound heard over the heart that indicates turbulent (unsteady, violently) blood flow through the heart valves.
Orthopnea
Positional dyspnea
Clubbing
Chronic respitory disease
Chronic hypoxia
S2
Is the second heart sound described as “DUB”.
Occurs near the end of ventricular contraction (systole) when the pulmonary and aortic valves close
page 340-341
Differential diagnoses
A list of possible conditions or diseases that could be causing the symptoms. `
Wheezing
Suggests lower airway obstruction
Is a high-pitched whistling sound that is most prominent on expiration but can be heard on inspiration in sicker pts
If only present unilateral suspect aspiration of foreign body or infection
If present bilateral suspect asthma
page 565
COASTMAP
C - Consciousness O - Orientation A - Activity S - Speech T - Thought M - Memory A - Affect (mood) P - Perception
A detailed mental status exam
page 584
Petechia
Pinpoint hemorrhage (kinda looks like freckles) - petechial hemorrhage – pinpoint red dot in the sclera of the eye
Pinpoint pink or red marks on skin, eyes
Petechial – characterized by small purple, nonblanching spots on the skin
Diaphoresis
Excessive, abnormal sweating in relation to your environment and activity level
The 5 P’s
Pain Pallor - pale Paresthesia - tingling, pins and needles Paresis - weakness, partial paralysis Pulselessness
Used to evaluate a limb for ischemia
page 581
Urticaria
aka Hives
Is multiple small, raised areas on the skin that may be one of the warning signs of impending anaphylaxis
Aortic valve
Left SL - semilunar- valve.
Separates the left ventricle and aorta
Plantar reflex
Normal response to stroking the sole of the pt’s foot
toes curve downward
page 308
Dyspnea
Shortness of breath
Diplopia
Double vision
Crackles
aka rales
fine crackles - sounds like rubbing hair between your fingers next to your ear
course crackles - sound more like small popping sounds and easier to hear
Indicates cardiac failure or infection, especially in young children
Crackles happen when oxygen/air passes through moisture in the bronchoalveolar system
Battle sign
aka Retroauricular ecchymosis or Raccoon eyes.
Skull fracture
Bruising over the mastoid bone behind the ear,
which may indicate a basilar skull fracture
Mitral valve
Left atrioventricular valve.
Separates the Atrium and ventricle on the left side
Pulmonic valve
Right SL - semilunar - valve.
Separates the ventricle and the pulmonary arteries
Rooting reflex
Occurs when something touches an infant’s cheek
the infant will instinctively turn his or her head toward
the touch
Abducens
#6 Movement of eyeball in a lateral direction
Minimum pedi systolic
70mmHg + (2 x age in years)
ABCDE
Airway Breathing Circulation Disability Exposure
Oculomotor
#3 Eye movement; elevation of upper eyelids; regulation of pupil size
page 309
Bruit
Abnormal whooshing sound heard over a main blood vessel that indicates turbulent blood flow moving through a narrowed artery
Mottled skin
Cardiovascular ‘embarrassment’ (as in shock), disseminated intravascular coagulopathy (DIC)
Patchy dark spots
Olfactory
Reception and interpretation of smell
Trochlear
#4 Movement of eyeball in a downward, inward direction
Pleura friction rubs
Squeaking or grating sound
Occurs when the pleura linings rub together when they have lost their lubrication most common from inflammation
Hyporesonance
aka Dullness
Indicates that the fields of the lung are full of blood
Hemophilia
Genetic disorder usually inherited from the mother
With this people have significant decrease in one of their clotting factors
Pt’s bodies have a lot more difficulty stopping bleeding.
Traumatic Fracture
occurs when abnormal forces are applied to normal bone structures.
Moro reflex
Aka startle reflex
Occurs when an infant is caught off guard by something or someone
Infant opens arms wide, spreads the fingers and seems to grab at things
S1
The first heart sound described as “lub”.
Occurs near the beginning of ventricular contraction (systole) when the tricuspid and mitral valves close.
Happens simultaneously
page 340-341
Visual Acuity
Sharpness of vision. How well a pt can see. Measure by doing finger count and asking is this dark or light.
Rhinorrhea
Runny nose
DIC
Disseminated Intravascular Coagulopathy (DIC)
Condition in which small blood clots develop throughout the bloodstream. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding.
Pathologic Fracture
occurs when normal forces are applied to abnormal bone structures
Reflection
Restating a word or phrase the pt told you so that you can confirm what you heard and get more detail from the patient
